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Health Information

Your safety and wellbeing is of paramount importance. Hypnotherapy is a tried tested and safe procedure. However it is important you provide the following information so I can identify in in advance if there may be any factors in your medical history that might impact the effectiveness of the therapy provided.

Do you suffer from or ever had an epileptic fit? *

• Yes
• No

Do you suffer from Asthma?

• Yes
• No

Do you suffer from Diabetes?

• Yes
• No

Are you taking any form of anti-depressants?

• Yes
• No

Have you received any treatment from or been prescribed any medication from a psychiatrist?

• Yes
• No

Have you ever been diagnosed with psychosis schizophrenia or bipolar disorder?

• Yes
• No

Have you ever had any suicidal thoughts?

• Yes
• No

Name *

Date

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